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General NPI Number Information
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NPI Number | 1518310333
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Entity Type | Individual
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Provider Name | GASTON JEREMIAH PHYSICIAN ASSISTANT
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Gender | Male
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Dates
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Enumeration Date | 07/16/2016
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Last Update Date | 06/21/2024
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Provider Practice Location Address
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Address Line | 1310 W STEWART DR STE 503
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City | ORANGE
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State | CA
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Zip | 92868-3856
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Country | US
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Telephone | 714-997-2224
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Fax | 714-997-1187
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Provider Business Mailing Address
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Address Line | 820 SUNGROVE PL
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City | BREA
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State | CA
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Zip | 92821-4130
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Country | US
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Telephone | 646-299-2402
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 3746
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 3746
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 55591
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License Number State | CA
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